THE SCHIZOPHRENIA SOCIETY SUBMISSION TO THE MENTAL HEALTH COMMISSION OF CANADA April 2009 INTRODUCTION The Schizophrenia Society of Canada (SSC) exists to improve the quality of life for those affected by schizophrenia and psychosis through education, support programs, public policy and research. The development of this submission to the Mental Health Commission of Canada (MHCC) in response to the national mental health strategy framework document Toward Recovery and Well-Being, represents an important part of our effort to help shift public policy and thus improve the mental health system. We recognize that this phase of the process for the MHCC represents the development of WHAT a transformed mental health system should look like and have provided our comments accordingly. In the next phase, when the MHCC develops the roadmap for HOW the goals can be achieved, we will submit more detailed recommendations. It is our hope that the dialogue between the SSC and MHCC will be ongoing and meaningful as the estimated 275,000 Canadians with schizophrenia and their families have an important stake in the outcomes of this work. SCHIZOPHRENIA Schizophrenia is a serious but treatable brain disorder that affects approximately one per cent of Canada s population according to the Public Health Agency of Canada. The symptoms include delusions, hallucinations, disturbances in thinking and communication, and withdrawal from social activity. Unfortunately, it is a disorder that often develops among people 15-25 years of age a critical developmental period in a young adult s life. 1 In addition to the significant impact on personal quality of life, of both the person with the illness and their family and friends, schizophrenia and mental illness have a significant economic impact. According to the May 2006, Out of the Shadows at Last report, the value of lost productivity in Canada that is attributable to mental illness has been estimated at $8.1 billion. If substance abuse is taken into account, the estimate grows to a loss to the economy of approximately $33 billion. 1 Canadian Psychiatric Association and the Schizophrenia Society of Canada, Schizophrenia: The Journey to Recovery, A
2 The need for early intervention, timely assessment, appropriate treatment and successful integration into the community with ongoing support is essential for the road to recovery for individuals with schizophrenia and psychosis. RECOMMENDATIONS The SSC supports the Mental Health Commission of Canada and the need for a mental health strategy that will guide the transformation of our current mental health system. We also support the eight goals and associated principles in the mental health strategy framework document Toward Recovery and Well-Being. In summary, the mental health framework document argues that in a transformed mental health system: 1. The hope of recovery is available to all; 2. Action is taken to promote mental health and well-being and to prevent mental health problems and illnesses; 3. The mental health system is culturally-safe, and responds to the diverse needs of Canadians; 4. The importance of families in promoting recovery and well-being is recognized and their needs are supported; 5. People of all ages have equitable access to a system of appropriate and effective programs, services and supports that are seamlessly integrated around their needs; 6. Actions are based on appropriate evidence, outcomes are measured and research is advanced; 7. Discrimination against people living with mental health problems and illnesses is eliminated, and stigma is not tolerated; 8. A broadly-based social movement keeps mental health issues out of the shadows forever. However, we believe that individuals with schizophrenia and psychosis have unique needs and in an effort to address these needs, we submit the following recommendations for your consideration and ongoing dialogue. 1. Include Best Practices for Those Affected By Schizophrenia and Psychosis The best way to manage schizophrenia is through a combination of medication therapy and a range of other approaches which are collectively called psychosocial interventions. These approaches can complement medication therapy to improve clinical symptoms, functional capability and quality of life. Effective psychosocial approaches can support people in following their medication plan, reduce the risk of relapse and re-admission to hospital, reduce distress caused by symptoms,
improve functioning and quality of life. These approaches provide support for patients, their families and caregivers. 2 3 The Schizophrenia Society of Canada is recommending a recovery-oriented national mental health strategy that incorporates the following best practices for those affected by schizophrenia and psychosis. The level of intervention is dependent on the need of the individual and the degree of his or her illness. Early intervention and diagnosis (First Episode Clinics) Early intervention is essential to helping an individual experiencing a first episode of psychosis on his or her path to recovery. A first psychotic episode typically occurs in a person s teens or early twenties and may develop into Bipolar Disorder or schizophrenia. 3 Early intervention has many benefits including: reduced morbidity, preservation of psychosocial skills, preservation of family and social supports, decreased need for hospitalization, more rapid recovery and better overall prognosis. The purpose of First Episode Clinics is to provide early assessment, timely and appropriate treatment as well as hospital admission if necessary. They can reduce wait times for assessment and treatment of schizophrenia and psychosis and should be available in each province and territory as standard practice. The number of clinics in each region should be based on population. Access to physical examination and appropriate testing A complete physical examination and appropriate testing should be conducted as part of an initial assessment of psychosis to rule out possible other causes such as a brain tumor, thyroid disorder, etc. Proper examination and testing of a patient is important before a diagnosis of schizophrenia or other mental health problem is made. As people with severe mental illness experience a 25 year shortfall due to comorbid issues (cardiovascular, metabolic disorders, diabetes, etc.) and a disadvantaged lifestyle, access to regular physical examination and appropriate testing about the ongoing needs of this population to primary care are critical. Access to a full range of treatment options o Antipsychotic medications fully accessible and covered by provincial/territorial public drug plans Antipsychotic medications have proven to be among the most important medical advances for treating schizophrenia. As a result of these medications, people with schizophrenia no longer need to be hospitalized for long periods of time. 2 Canadian Psychiatric Association and the Schizophrenia Society of Canada, Schizophrenia: The Journey to Recovery, A Consumer and Family Guide to Assessment and Treatment, 2007 3 Helen Buttery, Centre for Addiction and Mental Health, CrossCurrents, The Journal of Addiction and Mental Health available online at http://www.schizophrenia.com/family/early.diag.htm, sited on March 6, 2009.
The vast majority are able to live in the community, requiring hospitalization for the illness only if they relapse. 4 There are many types of antipsychotic medications and the type and dosage will vary for each person. 4 o Psychological support services such as Cognitive-Behavioural Therapy (CBT), talk therapy, etc. Cognitive-Behavioural Therapy is a form of psychotherapy that involves establishing a relationship, examining and challenging basic assumptions about one s life and setting small but feasible tasks that lead to long-term change. CBT has been shown to manage symptoms that persist even after medication treatment. o Concurrent disorders services (combination of a mental health problem and a substance use disorder) Programs and systems that treat mental health problems need to be transformed to be able to deliver integrated services for people with both schizophrenia and substance abuse problems. This means that cross-training is necessary for both care providers that support individuals with mental health problems and those that support individuals with addictions, to be able to deliver one program that meets the needs of those with concurrent disorders. o Psychosocial rehabilitation (social and life training skills) Psychosocial rehabilitation must be a strong component of any recovery-oriented mental health system. Social skills training is often necessary for patients who experience stress and anxiety about social situations. Similarly, proven life skills training is often necessary for patients who are having difficulty with tasks of everyday living in the community. o Appropriate discharge planning with meaningful engagement of both patient and family Hospitalization is only part of the recovery process for individuals with schizophrenia; therefore it is important that the patient and his or her family are supported after the patient is discharged. Support should include ongoing patient follow-up to ensure adherence with his or her treatment plan, as well as help with accessing the range of programs and resources available in the community. Access to enhanced community supports and services: The successful recovery of a person with schizophrenia requires the involvement of a number of approaches that go beyond medication and hospitalization. 4 Centre for Addiction and Mental Health website available at http://www.camh.net/about_addiction_mental_health/mental_health_information/schizophrenia/schizophrenia_treatment.html, sited on March 8, 2009.
Research and experience demonstrate that the most effective approach to recovery involves active participation of the individual and family in ongoing treatment and community supports. This includes the following: 5 o Access to mental health worker, occupational therapist, proctor, PACT team, etc. o Crisis Intervention services (Stabilization Units, Mobile Units, brief therapy counselors, etc.) o Peer support (Peer Support Specialist, self-help groups) peer support can lead to improved self-esteem, self-worth and the development of social networks that help to reintegrate people with schizophrenia into society. 5 o Vocational rehabilitation leading to meaningful employment and/or volunteer work o Safe and affordable housing of choice (independent, supportive or supported) o A full range of services and supports such as housing, income and employment opportunities - Individuals diagnosed with a mental illness such as schizophrenia should not have their income support restricted immediately upon securing employment. Often this creates undo hardship, particularly when the employment is temporary and lowpaying. o Meaningful family engagement (family psycho-education, family planning, etc.) o Sufficient trained staff working in a coordinated manner to meet the needs of the population in a particular area. 2. Adopt a Recovery-Oriented, Patient and Family-Centred Approach The SSC supports the shift toward a recovery-oriented, patient and family-centred mental health system that focuses on quality of life. It is important to build on the principles of hope, empowerment, choice and responsibility and to send a strong message to all Canadians that people with mental health problems and illness can live meaningful lives and be part of the community. However, the needs of those with a severe form of schizophrenia who may experience lack of insight must also be addressed with the potential utilization of the provincial Mental Health Act to prevent deterioration of health accompanied by potential harm to self or others. 5 Canadian Psychiatric Association and the Schizophrenia Society of Canada, Schizophrenia: The Journey to Recovery, A Consumer and Family Guide to Assessment and Treatment, 2007
We strongly agree with Goal 4, The importance of families in promoting recovery and well-being is recognized and their needs are supported. Meaningful engagement of family members in shared decision-making is important in collaborative care. We would add the following points: 6 Families should be actively involved in the planning and evaluation of mental health service systems. A very common concern of families is that their loved one may not consent to treatment, which may be due to the lack of insight associated with some forms of psychosis. However, family members in providing care often are not informed about various treatments, side effects, indicators of relapse, and discharge planning, etc. Preferably, where consent is not forthcoming, information may be released on a need to know basis if it has been collected for the purpose for which it is used, as in the British Columbia Freedom of Information and Protection of Privacy Act s. 33.2. 3. Implement Mental Health Legislation across Canada that Meets the Needs of Those With Severe Mental Illness. We recommend that mental health legislation across the country be assessed to determine if it meets the needs of people with schizophrenia and psychosis whose brain illness at the time may preclude them from accessing treatment voluntarily. These needs have been identified in this submission and include early intervention, protection from the harms the illness is likely to cause, reduction of relapses, and respect for rights etc. If reforms are needed and they can be done using identical wording in the 13 Canadian jurisdictions, then that would be helpful. However, all such legislation must conform with Charter rights and principles. Mental health laws deal with key issues such as involuntary hospital admission, authorization of psychiatric treatment, treatment refusal, community treatment and rights issues. We also recommend a review of the need for inter-provincial links in mental health legislation that would allow, for example, the inpatient or outpatient orders issued in one province to have legal standing in another should a patient cross a provincial border. Additionally, we think that it is important that legislation consistently balance the need for treatment of people with severe mental health problems and the need to protect the rights of these individuals. The rights of a person with schizophrenia or Bipolar Disorder are only suspended temporarily until they regain capacity and competency. In the interim they need an advocate and in the best instances, a personal directive to convey their wishes until they are competent logically to speak on their own behalf.
4. Introduce Diversion Programs across Canada 7 Too many individuals living with schizophrenia and other serious and persistent mental health problems and illness come into contact with the criminal justice system because of inadequate mental health systems and community services. The interaction with the criminal justice system often involves a relatively minor criminal offence. 6 Jails and prisons are not the places to treat individuals with mental health problems and illness who have committed minor offences. The SSC recommends ongoing efforts to divert these individuals from the regular court and prison systems, back to health and social support programs in the community where they can be more appropriately treated. There are at least three types of diversion programs: 7 i) Pre-booking Diversion Programs police officers work together with mental health crisis teams to deal with an individual who has engaged in behaviour that may result in an arrest or criminal charge. This program requires that police officers are properly trained and have ready access to in-hospital services. Training of police officers should include an understanding and use of the Mental Health Acts. ii) No-Plea Diversion for minor offences, an individual is charged but not required to enter a plea. Instead the individual is directed to mental health and other community services. iii) Plea-based Diversion for minor offences, an individual must accept responsibility for his or her criminal action and then is directed to take a judicially monitored program. If the program is successfully completed, charges are withdrawn or a non-custodial sentence is imposed. We need broader implementation of diversion programs and the decriminalization of individuals with mental health problems and illness. 5. Help to Reduce the Social Prejudice Associated with Mental Illness One of the myths associated with mental illnesses such as schizophrenia is that all individuals with the illness are violent. This misconception arises in part from isolated incidences of individuals who have a severe form of mental illness. The associated stigma also results in many not seeking and receiving treatment. The 6 Diversion and Mental Health Court Task Force, Schizophrenia Society of Canada, Diversion, Mental Health Courts and Schizophrenia, June 2005, available online at http://www.schizophrenia.ca/diversionpositonpapereng.pdf. 7 Ibid.
precursors to such incidents of violent behaviour, as documented by Health Canada 8 are often substance abuse/abuse, and/or a volatile personality. 8 This public misconception is exacerbated by the media who focus on extreme cases of violence associated with untreated, severe mental illness. The media should have a responsibility to report that the majority of people with schizophrenia live normal, quiet lives in their community. 6. Work Collaboratively with Mental Health Partnerships of Canada We recommend that the newly created charitable organization, Mental Health Partnerships of Canada, work collaboratively with existing mental health organizations to address the issue of research from a bio-psychosocial perspective. In addition, in order to sustain smaller organizations involved in transforming the mental health system, we recommend that consideration be given to providing funding grants to organizations that merit financial assistance and are in need of support. 7. Conduct Meaningful Engagement with all Stakeholders It will take the support of many stakeholders to implement the broad changes required to improve the health and social outcomes for those living with mental health problems and illnesses, as well as their families. We recommend therefore that the MHCC engage in meaningful dialogue and work collaboratively with the numerous individuals and groups that have been actively working in the community and at the regional, provincial and national levels to deliver programs, fight stigma, advocate for improved treatments and more timely services, conduct research and generally promote the need for better care. Their ongoing support for the work of the MHCC will be imperative to the successful transformation of the mental health system in our country. 8 Health Promotion and Programs Branch, Health Canada, Mental Illness and Violence: Proof or Stereotype?, 1996, available online at http://www.phac-aspc.gc.ca/mh-sm/pubs/mental_illness/index-eng.php
SUMMARY OF RECOMMENDATIONS 9 1. Include Best Practices for Those Affected By Schizophrenia and Psychosis 2. Adopt a Recovery-Oriented, Patient and Family-Centred Approach 3. Implement Mental Health Legislation across Canada that Meets the Needs of Those With Severe Mental Illness 4. Introduce Diversion Programs across Canada 5. Help to Reduce the Social Prejudice Associated with Mental Illness 6. Work Collaboratively with Mental Health Partnerships of Canada 7. Conduct Meaningful Engagement with all Stakeholders Thank you once again for this opportunity to provide our input into the vision for WHAT a transformed mental health system should look like. We look forward to reviewing the outcomes of this phase of the consultation process and our ongoing dialogue. Respectfully submitted, Dr. Pamela Forsythe, MD, FRCPC President Dr. Chris Summerville, D. Min, CPRP Chief Executive Officer 100-4 F O R T S T R E E T, W I N N I P E G, MB R 3C 1C 4 T E L: 204.786.1616 T O L LFRE E: 1.800.263.5545 E M A I L: I N F O @ S C H I Z O P H R E N I A.CA W E B S I T E: W W W. S C H I Z O P H R E N I A.CA C H A R I T A B L E R E G I S T R A T I O N # 106846553RR 0001